Idiopathic CD4 lymphocytopenia (ICL)

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist, Fort Lauderdale, FL

A 38-year-old male is at the allergy clinic here for evaluation of low CD4 count. The reason for checking his CD4 was that he volunteered to be involved in a research project 5 years ago. His absolute CD4 was 456 at the time. At that time, he was negative for both HIV-1 and HIV-2 type viruses, and the test was repeated in 3 years later. Since then, his CD4 count continues to be low. It was 432 three years ago. Despite the low CD4 count, however, he has no history of any infections or abnormalities related to it. He has history of difficulty gaining immunity against hepatitis B after vaccination, and after 3 separate vaccinations, he was not able to develop detectable IgG antibody against it. His flow cytometry from 3 years ago showed absolute CD4 count of 432, CD8 count of 379, CD19 count of 261, and CD56 count of 278. He had positive immunoglobulin G against measles and rubella 10 years ago. He does not recall any family history of immunodeficiency. He has no family history of allergic rhinitis, asthma or eczema or food allergy.

Past Medical History: As above. Past Surgical History: Negative. Current Medications: He is not on any medications on a regular basis. Family History: Unremarkable. Physical Examination: unremarkable.

What is the most likely diagnosis?

Idiopathic CD4 lymphocytopenia of unclear etiology at this point.

Any clues about the etiology of his idiopathic CD4 lymphocytopenia?

A variety of past or latent viral diseases can induce CD4 lymphocytopenia. Autoimmune conditions can also pay a role. In patients with asymptomatic CD4 lymphocytopenia in the absence of HIV infection and opportunistic infections, a genetic defect could be the cause.

What laboratory workup would you suggest?

Evaluate the function of the other parts of his immune system including B cells and T cells and humoral immunity.

Regarding his idiopathic CD4 lymphocytopenia, the suggested workup would include flow cytometry with CD4, CD3, CD8, CD19, CD26, CD56, and CD16, also immunoglobulin G subclasses, immunoglobulin G, A, M, and E, CBC with differential, immunoglobulin G titers for 23 pneumococcal serotypes, tetanus, diphtheria, hepatitis, and mumps, and also mitogen stimulation test for lymphocyte proliferation for B and T cells.

ANA, CMP, ESR and UA can also be addded to his laboratory work.

An evaluation by an infectious disease specialist for his lymphocytopenia is also suggested in order to rule out any latent viral infection that may play a role in his etiology.

Published: 06/12/2011
Updated: 08/23/2011

Facial angioedema after dental work - how to rule out latex allergy?

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist, Fort Lauderdale, FL

A 7-year-old boy is in the allergy clinic for evaluation for latex allergy. Three months ago, he had dental work done on 7 teeth on the same side (on the right) and 2-3 dental caps on the other side. The procedure lasted 22 minutes. Soon after, while in recovery, he developed facial angioedema. An allergic reaction to latex was presumed because the dentist used latex gloves. In the dental office, he received two epinephrine doises, antihistamines and Solu-Medrol IV (methylprednisolone). Despite that, it took about a week for the swelling to subside.

His specific IgE testing (sIgE) for latex (ImmunoCAP) was negative. However, ImmunoCAP test is only helpful if positive (similar to sIgE for penicillin). A negative specific IgE test for latex does not rule out latex allergy and he was scheduled for skin prick test and challenge with the same. The dentist provided the same type of latex glove that he worked with during the procedure.

Past Medical History, Past Surgical History, Social History are unremarkable. Medications: none. Physical Examination: unremarkable.

What is the differential diagnosis in this case?

- Latex allergy
- Postoperative facial edema secondary to local trauma
- Allergic reaction to anesthetic or antibiotic

What test would you suggest?

Skin prick testing with latex, followed by challenge if the skin test is negative.

What happened?

He had skin prick testing with latex. It was performed with the same type of latex glove that the dentist was wearing during the 22-minute surgical procedure that was was followed by suspected angioedema.

The skin test was done with the prick-puncture technique with:

- negative/positive control
- wet glove
- wet glove solution
- dry glove

The skin prick test with latex was completely negative.

This was followed by a negative challenge test: with rubbing of the latex glove on his left hand, there was no reaction, and then the latex glove, with powder on, was rubbed on his right cheek, and again he had no reaction immediately, and then during the observation period, 40 minutes after the test. This is considered a negative skin prick and challenge test with latex.

Final diagnosis

Postoperative facial edema secondary to local trauma. There is no evidence of latex allergy, especially with negative skin prick test, specific IgE, and direct challenge with latex. The differential diagnosis includes an allergic reaction to anesthetic or antibiotic.

Summary

This is a patient with facial edema soon after dental procedure involving work on multiple teeth. It was initially attributed to latex, however, he had negative specific IgE testing for latex. Also, he had a negative skin prick test for latex today and a negative skin challenge with latex. In addition, he has a long history of exposure to latex products and they do not report any allergic reactions, including when he plays with balloons with latex powder.

There is no contraindication to using latex products or latex gloves during surgical procedures.

List of some common products that may contain latex

Rubber sink stoppers and sink mats
Rubber or rubber-grip utensils
Rubber electrical cords or water hoses
Bath mats and floor rugs that have rubber backing
Toothbrushes with rubber grips or handles
Rubber tub toys
Sanitary napkins (that contain rubber)
Condoms/diaphragms
Diapers that contain rubber
Adult undergarments that contain rubber
Waterproof bed pads containing rubber
Undergarments, socks and other clothing with elastic bands that contain rubber
Adhesives such as glue, paste, art supplies, glue pens
Older Barbie dolls and other dolls that are made of rubber
Rubber bands, mouse and keyboard cords, desktop and chair pads, rubber stamps
Mouse and wrist pads containing rubber
Keyboards and calculators with rubber keys or switches
Pens with comfort grip or any rubber coating
Remote controllers for TVs or VCRs with rubber grips or keys
Camera, telescope or binocular eye pieces
Bathing caps and elastic in bathing suits

Tests to rule out latex allergy

- Skin prick test with the liquid from the soaked latex glove, and then if that is negative, apply a wet glove to the forearm and prick through the glove. If all of the above are negative using the same gloves the patient has used in the past it would make the diagnosis of latex allergy unlikely. This should be followed by a challenge when appropriate.

- Specific IgE blood test may be helpful but the skin testing is the preferred diagnostic method.

- Pre- and post- pulmonary function tests as objective confirmation of obstruction if a patients complains of shortness of breath but did not exhibit visible cutaneous manifestations

References

Latex Allergy. Cleveland Clinic.
Latex-free Consumer Products. American Latex Allergy Association.
Latex Allergy. The American Family Physician, 1998.
A patient information handout on latex allergy.

Diagnosis of latex allergy. AAAAI Ask the Expert, 2011.

Approach putative reactions to local anesthetics by a skin test followed by a “graded challenge” protocol goo.gl/vJfQp
Contact dermatitis to latex surgical gloves? There are limited choices for non-latex gloves: vinyl or nitrile. AAAAI, 2011.

Published: 05/12/2010
Updated: 12/22/2011